Addiction Recovery Basics

Moyers: So why doesn’t the brain get addicted to broccoli?

Hyman: The simple answer is that broccoli doesn’t have chemicals in it which short-circuit the system and provide abnormally elevated rewards. Because what people who use cocaine or amphetamine discover is that they can circumvent all of the work it normally takes to get some natural reward. I’ve talked about discovering the good taste of a new food. But imagine that you’ve just finished a marvelous documentary. And you feel a certain amount of pride and reward and you get a certain amount of dopamine for that.

Moyers: Till I read the review.

Hyman: Till you read the review, exactly. Then your amygdala (which codes fear and anger, amongst other things) starts firing.

Moyers: [LAUGHS]

Hyman: Basically the drug abuser finds that these drugs, at least initially, give them a kind of euphoria. A kind of self confidence. A feeling that they can achieve only with extreme difficulty using natural stimuli.

Moyers: There’s no natural high quite as high as a drug high?

Hyman: No, because the drugs really do trick the brain. Cocaine and amphetamine put more dopamine in key synapses over a longer period of time in this brain reward pathway than normal. And because they are so rewarding, because they tap right into a circuit that we have in our brains, whose job it is to say something like, “Yes, that was good. Let’s do it again and let’s remember exactly how we did it,” people will take these drugs again and again and again.

Moyers: What about tobacco? I mean, a lot of times when children smoke that first cigarette they will cough and choke because they don’t like it. But they’ll have another cigarette and another. What’s going on there?

Hyman: With drugs that are harder to like at first, like tobacco, people teach each other to enjoy them. The peers of a child trying his first cigarette create an atmosphere where that act receives approbation, where toughing it out is respected and cool. And pretty soon they get over the initial irritation and cough. And soon after that, they find out they’re hooked.

Moyers: And are they hooked because nicotine has done for this pleasure pathway what the cocaine has done for the user?

Hyman: Yes, though maybe not as profoundly. All of the most addictive drugs, either directly like cocaine and amphetamine or indirectly, like nicotine, alcohol, opiates, cause release of dopamine in this brain reward pathway.

Moyers: And because the dopamine is released I have the impression that something really good is happening to me?

Hyman: Yes, and here’s the important thing. You have a subjective feeling of euphoria. You feel when you take these drugs that something really good is happening to you. You feel, as I’ve said, either high or in the case of cocaine and amphetamines, that you have great confidence. The world is bright. The problem is that these drugs are like a sledgehammer in the brain. While the person is feeling this euphoria, other things are happening. You see, our cells have all kinds of mechanisms to adapt to powerful environmental stimuli that they see as a stress. It’s called homeostasis, trying to keep functioning well under constantly changing environmental conditions.

Perhaps the best example I can give you is going to the gym and lifting weights. The first time you go, you strain your muscles, right? You have sore arms after you lift weights. But if you go back to the gym and lift very heavy weights, (think drug dose), you do it enough times a week (think frequency of drug administration), and you do it for long enough (think chronicity), what happens? A signal goes from these poor strained muscle membranes to the very nucleus of the cell, which contains the genetic material. And it says basically, “We’ve got to adapt, we’re under a lot of stress here.” And the muscle cell turns on the genes that make structural proteins and over time we get what a body builder considers a very positive adaptation — big muscles.

Moyers: The gene is saying, “Hey, guys, I need more protein.”

Hyman: Exactly, “Give me more protein.” Now let’s go to the drug addict’s brain. Here’s this poor synapse which has never seen so much dopamine for so long in its life, what is it going to do? The dopamine on the one hand may be helping the drug user feel euphoria, but at the same time, the receptor cell isn’t very happy. It’s stressed. What happens? First, it’s trying to decrease the efficacy of this dopamine signal so it won’t hit it so hard, and it’s saying “Enough, too much.” It sends signals to other cells to say, “Turn this off.” So adaptation occurs, and we see the clinical realities of this when somebody ends a cocaine binge. At that point, there might be less dopamine in the brain or the dopamine that’s there might be less effective than prior to drug use. So after a cocaine binge, the brain is physically changed — it’s adapted. But that adaptation, less dopamine now, means that the drug user feels bad. The drug user can’t feel pleasure. The drug user might feel depressed and is craving more drug.

Moyers: His body is saying it wants more dopamine, he can’t get it, so he physically gets depressed.

Hyman: In effect, yes. But the addict doesn’t know that that’s what’s happening. What the addict knows, or thinks is correct, is, “I will feel better if I put myself back in this precise context where I felt good and use my drug.” This is the learning side of it, the emotional memory. It may not be true that taking the drug will make him feel better, but that’s what using the drug teaches him. And part of that memory is not only the emotion, but the whole context. The friends that they see when they are using drugs, the paraphernalia, the kind of room they are in or the kind of alley, all become attached to the ritual and the feelings of getting high. They become part of the brain’s “emotional memory.”

Moyers: That’s why AA talks about “people, places, and things.” Avoid the people you used with, avoid the places you used, and avoid the things associated with use like the pipe.

Hyman: That’s absolutely right. Remember, the dopamine in this brain reward circuit is still saying, “That was good, let’s do it again, and let’s remember exactly how we did it.” So there’s this emotional learning that goes on which is in many ways the longest lived change in the brain.

Moyers: Perhaps this is what we mean when we talk about indelible memories.

Hyman: I think that’s right. And one of the things that Alcoholics Anonymous says is that alcoholics are not recovered, they are recovering. I think they’re right because there are many things in the brain that make it likely that once addicted you’re at high risk of relapse and one of the most important is this indelible memory. We know that when people are detoxified and then they’re back in a situation where they used to use drugs, they may experience certain feelings. In the case of the cocaine user, they might feel a little bit high. Which makes them want more. In the case of the heroin addict, some of them actually feel a little bit of withdrawal, and that makes them want the drug. A common experience for ex-smokers is that they’ll have a festive meal and be reminded that they used to enjoy a cigarette at such times and they will feel waves of craving. These are cues which are awakening these powerful memories. When something is highly rewarding, we are likely to remember it vividly and also to remember the circumstances under which we encountered it. Even after years of abstinence, people may experience profound cravings and risk relapse if placed in the surroundings of their former drug use.

Moyers: You’ve referred to the reward circuit as part of the “old brain.” What do you mean, the “old brain,” and why might we have a reward region in the first place?

Hyman: Well, the idea of an older part of the brain really comes from study of comparative neuroanatomy that looks at lizards and evolutionary older mammals and compares them to primates and humans. And what we see is a very developed neocortex in humans, which is the outer layer of our brain and has been linked with reasoning. Our cerebral cortex appeared relatively recently in evolution. But some of the emotional circuits in the brain have been around for a much longer time. That’s why they have gotten the moniker “the lizard brain,” because of their evolutionary history. But it’s unfair to equate all of our emotions with lizards because after all, they do a lot of good things for us as well. What makes us fundamentally human is not thinking alone or emotion alone but a combination of the two. In fact, what makes us different from computers is certainly emotion. And some of the highest human feelings like love or altruism are human, as well as fear or anger or pain which we share with lizards. It’s the interweaving of emotion and cognition that allows us to make any decision that we make in life. The important thing is that we have dedicated circuits in the brain which are involved in emotion. I mean, imagine the world without emotion. All meaning would drain out of it — it would just be a world of cold facts. The world comes to us instead, full of rich meaning. Things have a valence. They make us happy or sad. Some things are fearsome, some things are enjoyable, some make us curious. Some are edible. And the emotional part of our brain is making appraisals. It’s saying this can hurt us, this is good for us. And in making those appraisals, the emotional parts of our brain start all kinds of downstream reactions. The emotion of fear, for example, starts our hearts racing.

Moyers: But what does this have to do with that old lizard brain? Why would the lizard have eveloped a brain that would assign priorities of value?

Hyman: Well, probably not so that it could write philosophical texts about value. The circuit most likely developed to control behavior quickly. At the simplest level, any animal needs to be able to judge what to avoid and what to approach. It needs to evaluate situations and react to them immediately. It can’t be sitting there thinking, “Hmmm. Is this food or is this something that will eat me?” It has to react as soon as a threat is spotted, otherwise it won’t live very long.

Emotions really are circuits in our brain that allow us to survive. Now this is speculation, but just imagine some of the roles for this reward circuit in evolution. Without something to make sex appealing, nature’s experiment with sexual reproduction would have been a great failure. We would have been perhaps budding like yeast or something, with no need for a sexual partner or the sex act. And while that sounds kind of silly, the fact is there has to be something extremely compelling about reproduction in order to get the job done because, as any parent knows, the process of having a child is not always easy. If sex gave no pleasure, or you didn’t remember or desire that pleasure, you wouldn’t reproduce yourself. But also, evolution couldn’t hardwire every possible response into our brains. We’re going to encounter all kinds of new and unexpected situations in our world. And so this reward circuit has to be able to learn. And when it’s something like a new food that’s good for us, or something that is healing or useful, then we’ve learned about something that’s going to be adaptive.

Moyers: Let me make sure I understand this. In terms of survival, the more relevant something is to survival, the more likely we are to remember it?

Hyman: That’s very well put. The more relevant something is to our survival, the more likely we are to remember it. Again, let’s contrast having to study some dry as dust material in the classroom, where you have to rehearse and rehearse to remember it, and compare that with something that’s really emotionally charged. You just don’t forget your first love, but most of us forget the Pythagorean theorem. The other thing which is very important is that key parts of memory are not necessarily conscious. They are memories that get us to control behavior — that motivate us, if you will. So, for example, if you encounter something that has hurt you badly in the past — let’s imagine you have been bitten by a snake once, and you’re now hiking along and you find yourself in just the kind of country where you were bitten before — before you even realize it, you might find that your heart is racing, that your palms are sweaty, and that you’re vigilant and ready to escape. I think the important point here is that emotion paints the world with meaning. Emotion says this is important, that is dangerous, this is good. And it paints the experience in such a way that our conscious minds may be involved but all kinds of unconscious processes are also involved.

I think some of the stigma of addiction results from a misunderstanding of these unconscious processes. Because the illness is largely invisible, but also because when people look inside themselves, they don’t realize they can’t see everything that motivates their own behavior. We don’t recognize, for example, that when I reach over to point my finger at you, all kinds of things have happened in the background of my brain. It calculated a trajectory, it stabilized my shoulder girdle, it told certain muscles to fire up so many hundred milliseconds and opposing muscles to fire up so many hundred milliseconds. If I had to calculate the trajectory and do the fine tuning as I approach my target, I don’t think I would be very successful in pointing at you; in fact, I might well hit you instead. And it’s the same thing with emotional processing. Lots of things which we aren’t wholly aware of are going on in the background, telling us about the emotional valence of the world. For the addicted person, it’s saying, “You know, you better get another drink now because we’re running out here and the world’s getting pretty bleak.” Addicts aren’t willfully choosing those background thoughts and feelings and drives, and non-addicted people don’t have to contend with them.

Moyers: Are those background thoughts predetermined?

Hyman: Well, with reproduction, for example, the desire is very much hardwired. Witness all of the hard work that people have to do in order to avoid sexual desire when in certain religions they decide they’re going to be celibate. It takes a great act of will to overcome, in this case, these very hardwired desires that evolution, interested as it was in reproductive success, put into us.

Moyers: What do you mean, “hardwired”?

Hyman: Certain responses in our brain, like sexual desire, develop through pre-existing genetic programs which we are born with. We may experience aspects of sex and find them good or rewarding or disappointing or what have you, but we are born to find sex pleasurable. If people were designed to avoid sex, there wouldn’t be too many of us around, would there? But because the world is complicated and unpredictable, nature could not have built in a list of everything that was going to be good, of everything that could hurt us, of everything we ought to be afraid of. And so these emotional circuits have some built in functions, but perhaps the most important thing they do for us in our lives is, they learn. But there can be a danger here because in many ways emotional circuits take our higher processing out of the loop. They literally cut it out, by bypassing those pathways and — crucially for our understanding of addiction — push our behavior before we’ve really had time to look rationally at all its implications. And so when you’ve learned to like a drug, you find you’re already going after it before you’ve thought about it. If you talk to an alcoholic or a drug addict, they will tell you they often wake up in the morning and they say “I’m not going to use today. Right. In fact, I’m never going to use again.” And then they go out in the world and they see their drinking buddies and the sight of them taps into these emotional memories. The voice of reason, of conscious control, becomes a rather small voice in competition with this intense emotional sense of craving and need.

Moyers: So while the rational brain has said “never again,” the emotional brain circumvents it?

Hyman: That’s right.

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